Healthcare Provider Details

I. General information

NPI: 1497371652
Provider Name (Legal Business Name): JACKSON GRAY PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 E FAIRMOUNT AVE
BALTIMORE MD
21231-1534
US

IV. Provider business mailing address

2809 BOSTON ST APT 123
BALTIMORE MD
21224-4815
US

V. Phone/Fax

Practice location:
  • Phone: 920-621-7263
  • Fax:
Mailing address:
  • Phone: 920-621-7263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number06711
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: